Provider Demographics
NPI:1558845594
Name:WILSON, SCOTT (ARNP)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18150 MURDOCK CIR BLDG G
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-4027
Mailing Address - Country:US
Mailing Address - Phone:941-623-4444
Mailing Address - Fax:
Practice Address - Street 1:18150 MURDOCK CIR BLDG G
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-4027
Practice Address - Country:US
Practice Address - Phone:941-623-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-15
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9370829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101890500Medicaid